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I recently visited India (Delhi) after a gap of about 18 months. Here are a few observations:

Health Insurance is taking off. Many private companies offer them as a benefit. Self Employed individuals are also purchasing it. Typical annual premiums are INR 3-4K for INR 100K coverage for a family of 4 with the parents in their 30s. The services are being marketed aggressively.

The availability of drugs and equipment is much better than before. Medical distribution is a hot business to be in since the increasing prosperity of the general population is leading to an even faster growth in expenditure on health-care.

However, private hospitals are minting money at the expense of insurance companies and wealthy individuals.

In the US the Medicare system fixes rates at which the govt. will pay health care providers (HCPs) for different services. The Medicare rates are broadly based on cost analysis and form the basis for rate negotiations between private insurance companies (PICs) and HCPs. The PICs also provide guidelines in terms of normal and reasonable care needed (e.g. length of hospital stay after a surgery, child-birth) which they will pay for. So the PICs and Medicare determine what the HCPs charge for the services.

In India, this costing mechanism is missing. A diagnostic test which requires INR 50 worth of material is often billed at INR 500. The amount billed is very often based on the paying ability of the "party". If a patient is covered by insurance, the medical bill due to hospitalization creeps up. The insurance companies do not seem to have adequate safeguards in place to check for over-medication, excessive billing etc. since no costing mechanism seems to be in place.

Wealthy individuals are also taken for a ride: a dying man will be kept alive on a ventilator for 3 days and run up a bill for INR 200,000!

These are signs of an industry in infancy. There seem to be a big oppurtunity in managing health care in India. Hopefully, professional management provided by the Medical Insurance Companies will lead to cheaper access to better health-care to a lot more Indians.

The cost of hospitalization for procedures is easily an order of magnitude (10x) less than the costs in the US. Many NRIs aware of this are already taking advantage leading to growth in "Medical Tourism". However, this sector is unorganized.

This seems to be a huge market for Indian Health Care providers to access in an organized manner. Many European countries and Canada have National Health Plans funded by the government. An agreement with these agencies coupled with facilities dedicated to servicing these customers may help this segment to take off.

The argument against making India a "Medical Tourism" destination is that it will further reduce the accessibility of quality health-care to Indian Nationals. In order to address this genuine and valid concern, a portion of revenues generated by Medical Tourism should be invested in a training-trust fund. This fund should focus on setting up new training and care-providing facilities, while upgrading the infrastructure and quality of existing facilities.

We do not have a shortage of smart people who can become good doctors. What we have is a shortage of investment in "high-quality" training and facilities which the "Medical Tourism" money can fill in.

A lot of legwork is needed for India to enter this market in an organized market. Legislative action in India working our how this arrangement will work (e.g. what percentage of revenue to go to the training trust fund, who will manage the trust fund, privacy issues, liability issues etc.) might be the first step. Working an arrangement with foreign govts. and insurance providers is another hurdle which may take years to materialize.

Apart from providing employment to many, Medical Tourism, if executed properly, may also lead to better quality of healthcare for the average Indian.

Originally posted by VikramS:In the US the Medicare system fixes rates at which the govt. will pay health care providers (HCPs) for different services. The Medicare rates are broadly based on cost analysis and form the basis for rate negotiations between private insurance companies (PICs) and HCPs. The PICs also provide guidelines in terms of normal and reasonable care needed (e.g. length of hospital stay after a surgery, child-birth) which they will pay for. So the PICs and Medicare determine what the HCPs charge for the services.

In India, this costing mechanism is missing.

From 1965 to 1983 Medicare paid pretty much whatever the hospital billed them. It was only in 1983 that they introduced Diagnostic Related Group (DRG) based payment system. So yes in a way you are correct that Indian Health Insurence system is in its infanacy. But you are missing the fact that it took 18 years for Medicare to establish the DRG based system and in those 18 years it became the 800 lb gorilla in healthcare that it is today. By 1983 these hospitals were so dependent on Medicare payments that they really could NOT dictate to medicare anymore and Medicare was in control.

Thats what happens when you have a very influencial single payer in the market. In India there is no large single payer yet so no one company has the market leverage.

Also the demographics covered by what you called PIC (its managed care entities essentially slight difference from tradtional health insurence as you define it) and medicare are different for most parts. Managed care gets to 'cherry pick' and hence have traditionally the working and more healthy populace than Medicare. Depending on the lives covered and market penetration they may either own their own hospitals or negotiate a discounted per diem rate. They dont always use DRG base payments coz the diagnosis of their cohort is different from Medicare cohort.

You are quite right that those with insurence are billed exhorbitantly in India but that will change when there is more uptake of insurence. Once insurance really catches on then things will change coz the main source of revenue for all these hospitals will be insurence and then insurence will control the market......we are all doomed.

Originally posted by George J:You are quite right that those with insurence are billed exhorbitantly in India but that will change when there is more uptake of insurence. Once insurance really catches on then things will change coz the main source of revenue for all these hospitals will be insurence and then insurence will control the market......we are all doomed.

I think services is an area where Indian industries can really learn from their American counterparts. Thanks to dynamism inherent in the US system, Americans have pretty much seen it all. Their experience can be very valuable in ensuring that we in India do not commit the same mistakes.

Currently many govt./PSU servants get health coverage. It basically works off the "Panel System" where hospitals are authorized to be approved care providers. I am not sure what the payment formulae are. I presume that they have certain guidelines for compensation for different diagnosis/procedures. From what I understand, there is no central authority which makes these decisions. Perhaps a first step towards rationalization of the cost structure can be focussed on the government provided health care.

Would GOI be interested in buying insurance from PICs instead of acting as an insurance company itself?

India cannot learn anything from the US. The US is not the best mertic for equitable healthcare systems in the world. The US knows it the world knows it too.

If we need to emulate anyone should be UK's National Health Service.

The CEO of a 'very influential' hospital commented to a group of us very recently that frankly healthcare is a public service and if the US Gov says that it has no role in it then its patently wrong and hypocritical coz they run Medicare, subsidize Medicaid and completely bankroll the Veterans Admin*. So to be schizophrenic and say that let the markets decide is stupid.

For its size, complexity and priorities there is no way in hell that GOI should/will let insurance industry run amock. Till now the safety nets in India seem to be working. Healthcare is still pretty affordable and there is drug price control. I am not sure if the use of ESIS and CGHS is the best paradigme to follow for the future.

_______________________ VA serves only 6 million people in the US and is 33% more funding that UK's National Health Service. Point to ponder.

Nope the canadian system has invested a lot of control in the individual province...and hence when you move from one province to another you are faced with differing rules. It is publicly funded but not uniform.

I think i need to rephrase my point. There is no PERFECT healthcare paradigme out there. Each one is coping with legislating and economic environment they are supposed to be functioning in. Each has differing populations, differing access to resources: manpower, infra, materials, etc. And each has evolved over time.

I support the single payor system: UK NHS. I support government involvement in healthcare. Let the market spawn as many providers and third party admins as it wants but there should be only one payor. This is good economics. The payor will ultimately control costs based on utilizations and the payor will ultimately set policies that are more equitable for the masses.

Also from what i understand insurance lingo 'health insurance' is a loss leader there is way too much risk, no matter how you pool it it takes one outlier to make your profits go poof. You make moocho dineros with life insurance coz it actual does have predictable outcomes. The reason to have health in your insurance portfolio is coz you can take advantage of the underwriting cycles and invest the premiums in the market and hopefully offset any losses incurred by the profits from the markets.

Finally, I dont give a flying F*** for the 200 million middle class in India. There are 800 million poor in this country that need care too. Unregulated-multi-payor health insurance will only add to the chaos. Even the US gov takes care of its poor and the old. What do we do in India for them? The US cant handle 48 million uninsured what will we do with 800 million?

Originally posted by Ashutosh:Yeah, but's it's universal, and when moving from one province to another all that one has to do is exchange health cards free of cost. That's it.

Please read my edited post above for more clarification.

Regarding the exchange of insurance card I think we are talking about two different but equally important concepts. You are talking about the 'availablity and access to healthcare' I am talking about the 'availablity and quality of healthcare'.

Example: I go from British Columbia to Quebec and I take Ace Inhibitors. BC has 'reference pricing' for this class of med and hence the prices are fairly stable and cheaper. Quebec may not have it and hence while I can still get my rx filled its gonna be a bit more expensive. The difference may not be earth shattering but multiply that with the entire cohorts of taking these drugs and suddenly you find that two difference provinces spend differently for the same drugs.

From personal experience - at least in Ontario, Canada, the quality of healthcare sucks. The nurse to patient ration is very low and doctors have very low morale and do not deliver a good service. On top of that there are very few tools available to the public to hold doctors accountable for their actions.

The UK's NHS is a far superior system. Despite waiting lists, the quality of care is superb.

In a country where a small minority pay any income taxes it will be almost impossible to fund a National Health Scheme. The quality of primary care provided in the rural parts of the country can be significantly improved, by making sure that the current funding is utilized properly. Another big area which can needs supervision is the quality of a number of private medical schools which have sprung up in the last two decade. In many cases, these have become another avenue for politicians to mint money.

Bringing the discussion back to the issue of insurance and private hospitals. I am not commenting on the quality of the US health care system when I talk about learning from them. But we can definitely learn from them when it comes to the costing mechanism, recommended treatment plans, the checks and balances needed to keep the system working (e.g. co-payments), liability issues etc. Also this does not preclude us to learn from the Brits or the Canadians when it comes to understanding government funded health care.

Do the world owes anything to american enterprise for eradicating Small Pox, Malaria, heart diseases, etc, etc?

Current American Healthcare is bad because of the influential drug research companies lobby to keep the medical care prices high while canada, uk, india, china, etc benefit from all of their research. Modern Healthcare is as big gift to world as other american innovations like Cars, Airplanes, Computers and electercity.

Americans are unfortunate to live in a country where they create new drugs but can't pay to use them.

"A $40-billion-plus market growing at over 20% a year throws up huge opportunities for anyone smart enough to tap into it."

If properly harnessed the medical tourism market could be an even bigger bonanza than the IT sector. It can do wonders by increasing the quality of care available to the Indian citizen if the profits from the medical tourism industry can be pumped back into improving the local infrastructure.

Further, it is much less likely to encounter political backlash. A lot of folks in the West will be happy to pay less in taxes which fund Medicare/NHS etc.

It is essential to allow the private medical colleges in the South, particularly places like Tamil Nadu...Also consider some more of colleges in the North. It is good that the BJP has introduced some AIIMS in many parts of India...

"Nope the canadian system has invested a lot of control in the individual province...and hence when you move from one province to another you are faced with differing rules. It is publicly funded but not uniform."

This is almost meaningless as it can mean anything. You obviously have not practiced medicine in Canada or anywhere else.

His daughter-in-law Shanti Bai, 30, went to such a doctor for a fever six months ago. He gave her an injection. The next day, she was dead and her children motherless.

Villagers blamed the doctor and he fled, but the heartache remains. Mr. Pandore and his wife have broken the news to their 5-year-old grandson, but they are still telling their 3-year-old granddaughter that her mother is away on a trip. "She cries and cries and asks, `Where is my mother?' " he said.

India has a vast primary health care system to serve its billion people, with clinics for every 3,000 to 5,000. But the system is often just a skeleton. New studies have documented the startling, damaging dimensions of chronic absenteeism — and not just in India.

Originally posted by James Bund:"Nope the canadian system has invested a lot of control in the individual province...and hence when you move from one province to another you are faced with differing rules. It is publicly funded but not uniform."

This is almost meaningless as it can mean anything. You obviously have not practiced medicine in Canada or anywhere else.

George is right! In Canada, Health is a provicial subject and the rules differs from province.

Originally posted by James Bund:This is almost meaningless as it can mean anything. You obviously have not practiced medicine in Canada or anywhere else.

Not all docs are policy wonks...not all policy wonks are docs. If its any consolation to you...I do this for a living. If you still dont believe me look up the impact of Rx reference pricing/covered services in BC and other province and its impact on migration from state to state especially for the elderly.

As US hospitals scout around to meet their crisis shortage of registered nurses, many from the Indian workforce find they qualify and are suddenly on the fast track for the coveted Green Card

By Stephen David

Philomena Bonjour, 34, had not taken an examination in almost a decade-not since she began her career as a nurse at one of Bangalore's oldest hospitals, St Martha's. But for days last year, she buried her nose in books often studying late into the night preparing for the exams that would qualify her for a nursing job in the United States. She attended month-long classes and took several practice licensing exams that, besides testing the medical education of the applicant, also tested her knowledge of American society.

Bonjour's hard work paid off: she cleared the Commission of Graduates for Foreign Nursing Schools (CGFNS) examination-the US exam that ensures all nurses employed in the US meet the required professional standards and are qualified to practise there. She also cleared the mandatory English tests-test of English as a foreign language (TOEFL) or the International English Language Testing System (IELTS)-as required. "I look forward to a new life in the US," she says.

Bonjour is not alone. Thousands of Indian nurses are preparing for a fresh start in America, where an acute shortage of nurses has sent hospitals scrambling to recruit from a growing network abroad. Among them is her own colleague Gloria Mohinani, 36, who is preparing to leave with her husband and child-unlike software engineers on a locational transfer (L1) or a work permit (H-1B), nurses who pass the exams get the coveted Green Card with perks thrown in like temporary housing and healthcare benefits. No wonder the migration route is easier through nursing today than the infotech highway.

The money is beyond what they could have dreamt of earning in India. "These nurses would earn anywhere between $25 and $30 an hour," says Revathi Sunkara, director of Indian operations, Nurses Anytime-the Bangalore branch of a US-based company that specialises in recruiting Indian nurses for the US. She adds that about 30 nurses from the company are currently ready to go. Nurses in India typically take home monthly salaries of about Rs 4,000, or $85, compared with American salaries of over $4,000 a month. Besides, points out Elizabeth Zachariah, principal of Florence School of Nursing in Bangalore, the working conditions abroad are much better and nurses can even opt for flexible timing.

The US has traditionally depended on nurses from Canada, Ireland and the Philippines. But with the shortfall in personnel increasing and with a highly trained, hard working workpool with excellent English language skills, India is emerging as a major source of trained nurses. A serious shortage of nurses is expected in the next three decades in the US. The US Census estimates that the population of 65 and older would double from 2000 to 2030 as the baby boomers move into this age group. During the same period, the number of women between 25 and 54 years of age-the traditional core of registered nurses (RNS)-is expected to remain relatively unchanged. In 2000, the national supply of RNS was estimated at 1.88 million while the demand was 1.99 million-a shortage of 110,000 or 6 per cent. If current trends continue, the shortage is projected to grow to 29 per cent by 2020. Indian nurses are patiently waiting to fill the gap. "It is the next revolution," says Malaka Reddy, Karnataka's medical education minister

In keeping with the demand, training and recruiting companies have sprung up across India to prepare nurses for American jobs. Bangalore alone has over 50 nursing schools and colleges, which in addition to preparing nurses for the exams, also coach them in cross-culture etiquette, accent orientation, grooming and give basic computer lessons. "The tests are tough. But if I pass, it means a new life," says J. Jainy, who has signed up with a Bangalore centre, some of which charge between $200 and $300.

Representatives of American companies often visit India to link up with local training centres for nurses. For instance, a team from Iasis Healthcare Corporation, a hospital company based in Tennessee, travelled to Bangalore to interview nurses-they are looking for about 300 recruitments a year.

Bangalore has emerged as a key scouting centre. "This is because of the large number of multi-specialty hospitals in the city," says Vijayashree Revankar, consultant, Health Careers Overseas at Y Axis-another firm that help nurses find jobs abroad. The proficiency in English among the Bangalore nurses is an added incentive.

An offshoot of the rising demand for Indian nurses can be seen in India too: men are now queuing up to marry nurses. Says one of the nurses who is all set to go: "There are so many men wanting to marry me, even without the dowry, just to go to the US."

Now nurses are flying into India from the Gulf as well to get their ticket to the West. Cynthia Kennedy who worked in the Gulf for eight years, is now looking at the American dream-the current destination after a record 1,800 Indian nurses were signed up by UK's National Health Service last year. Over 10,000 others are said to be counting on jobs in the West, the Middle East, Singapore, Australia and New Zealand.

However, given the stringent visa regulations in the US especially after 9/11, an exodus of nurses is unlikely. The result could be a long wait at the visa counter (see table). But that is hardly a deterrent to the likes of Bonjour who are happily chanting "westward ho". -with Anil Padmanabhan in New York

WASHINGTON, April 6 (Reuters) - The U.N., World Bank, the Global Fund to fight AIDS, Tuberculosis and Malaria and former U.S. president Bill Clinton said on Tuesday they had set up a joint plan to buy and distribute cheap, generic AIDS drugs in poor countries.

"We're talking of fixed-dose combinations of generic drugs, pre-qualified by the World Health Organization, to be purchased overwhelmingly from generic companies based in India, at prices as low as $140 per person per year."

"The pharmaceutical manufacturers included in these agreements are Aspen Pharmacare Holdings in South Africa; Cipla <CIPL.BO> in India; Hetero Drugs Limited in India, Ranbaxy Laboratories <RANB.BO> in India; and Matrix Laboratories in India," the U.N., Clinton and other groups said in a joint statement.

MADRAS, India -- Last year, Terry Salo flew 22 hours from his home in Victoria, British Columbia, to this southern Indian port city for a partial hip replacement.

Mr. Salo, a former commercial fisherman, faced a wait of a year or more for free care from Canada's national health service but the pain had become unbearable. Before airfare and other expenses, he paid $4,500 for the surgery at Apollo Hospitals Enterprises Ltd., a quarter of the cost for similar treatment in Europe and the U.S.

"People need to know that there are other options out there," says Mr. Salo, 54 years old, who was swinging golf clubs a month after the operation.

Mr. Salo is one of 60,000 foreign patients who were treated at Apollo Hospitals over the past three years. Since its start as a single hospital in 1983, Apollo has grown to 37 hospitals with more than 6,400 beds, making it one of the largest private hospital chains in Asia. Apollo's emergence as a global health-care provider in many ways tracks India's economic trajectory over the past three decades. The company has capitalized on the high cost of health-care administration in the U.S. and demands of patients elsewhere, for fast, inexpensive treatment.

Apollo's range of medical services -- from the back office to the operating room -- highlights the contradictions of the global outsourcing debate. In seeking to provide a wide range of services at a large discount to Western competitors, Apollo is yet another Indian company threatening jobs in the U.S. and other countries. On the other hand, Apollo's relatively inexpensive medical services have benefited patients from numerous countries. It also has helped India's overburdened health-care system. India has fewer than one hospital bed per 1,000 people, compared with more than seven in developed countries.

"We're showing that a field like medicine is very much a two-way street," says Prathap C. Reddy, 72 years old, a physician who founded Apollo and now runs it with his four daughters from Madras, also known as Chennai. "We can all grow from each other's strengths."

Apollo and a half dozen other private Indian hospital companies are adding patient rooms, buying new equipment and installing modern telecommunications gear. Meanwhile they also are setting up marketing offices in cities such as London and Dubai to attract patients, many of whom remain wary of seeking health care in the developing world. Few of Apollo's patients come from the U.S.

Growth Industry

The Indian government sees health care as a growth industry. Public and private Indian universities are churning out 20,000 doctors and 30,000 nurses a year, some of them destined for jobs in western countries. That is roughly triple the pace at which nurses were trained during the 1990s.

In the so-called medical-tourism business, the focus is on big-ticket surgical procedures from face-lifts to liver transplants. Asian countries such as Thailand, Malaysia and Singapore have taken the lead in this field. Promoting health-care services alongside tourist destinations, the countries attracted more than 600,000 patients in 2003 alone, according to officials in Thailand and Malaysia.

Apollo offers cardiac surgery for about $4,000, compared with at least $30,000 in the U.S. Apollo's orthopedic surgeries cost $4,500, less than one-fourth the U.S. price. Consulting firm McKinsey & Co. says medical tourism could become a $2 billion-a-year business in India alone by 2012; the category is so new it previously wasn't measured.

For now, foreign patients represent 7% to 9% of the overall mix at Apollo. Upon arriving in the country, they are greeted at airports by Apollo staff and whisked off to one of its hospitals. These outside guests are treated and housed in buildings with local patients, though they stay in private rooms with one-on-one nursing care. When fit enough to travel, some patients such as Mr. Salo visit seaside resorts as part of their package.

Mr. Salo warns that Westerners need to brace themselves for some real shocks. The sight of urchins and beggars roaming Madras's streets was disturbing, he says. The 100-degree heat was oppressive. He faced "real doubts" about his decision when he entered Apollo's emergency room and saw the ragged condition of local patients. Outside Apollo's hospitals, clean water and blood supplies aren't a given.

Apollo was a longtime dream of Dr. Reddy. The son of a wealthy mango and sugarcane-plantation owner, he studied medicine in India but moved with his wife to the U.S. in the 1960s, like many professionals of his generation. After a hospital stint in Boston, he set up what would become a successful lung and internal-medicine practice in Springfield, Mo. But he missed home and returned to India in 1970.

Steep tariffs blocked the import of state-of-the-art equipment at the time, and hospitals often had little choice but to attempt to send their most seriously ill patients abroad for care. In 1979, Dr. Reddy was treating a young businessman who needed coronary bypass surgery. Lacking the necessary equipment, he advised the man to fly to Houston. The patient couldn't afford to and died.

"I pledged to myself then and there that I would make certain India would have world-class facilities before I died," Dr. Reddy says.

While the country had some private charity-owned health-care facilities, the best-known established by the late Mother Teresa, many of Dr. Reddy's friends doubted he could start a profit-making hospital. "I never thought it would materialize," says Joseph Thachil, an Indian doctor and kidney specialist then working in Toronto and now a doctor at Apollo in Madras.

Initially, financial regulations prevented Dr. Reddy from raising funds from international banks and overseas Indians. There were limits on the amount of land private hospitals could procure. Government bureaucracy required multiple applications for imported equipment.

"I told him there was no precedent for what he was doing," says Manmohan Singh, India's finance minister in the early 1990s. "But he persisted," opening the first of his hospitals in a modest five-story building down a narrow lane jammed with ox carts in Madras. The hospital since has taken over a hotel that used to operate next door.

Apollo also attracted investment from units of Schroders PLC in the U.K., and Citigroup Inc. and Goldman Sachs Group Inc. in the U.S. Sharp drops in Indian tariffs, meanwhile, allowed the company to import gear almost as soon as it appeared in Western hospitals.

With barriers down, Dr. Reddy expanded rapidly. He formed a joint venture with the state government in New Delhi to build and finance a new hospital and franchised Apollo's services to bring 45 new clinics to other parts of India. He also signed deals with hospitals in Kuwait, Sri Lanka and Nigeria to contract out the company's management services. Today, Apollo operates in eight countries across South Asia, the Middle East and Africa.

But the core of its business is a fast-growing class of Indians who have the money to forego free treatment at state-owned hospitals. Of India's one billion people, roughly 250 million are considered middle-class. Complete checkups typically cost about $90 to $180. That is affordable to India's growing numbers of call-center workers and engineers -- though still out of reach for the very poor, estimated at about 300 million.

For the first three quarters of the fiscal year ended March 31, Apollo posted net income of the equivalent of $6.4 million, more than the $6.2 million it earned in the full prior fiscal year. Its revenue totaled about $84 million for the nine months, compared with $75 million during the same nine months of the year before. Nearly 62% of Apollo's revenue came from its core hospital business during the 2003 fiscal year; 36% came from pharmacies, and the balance from the newer outsourcing businesses.

The company expects the number of patients to grow about 20% per year over the next decade, and Dr. Reddy anticipates the outsourcing businesses will soon make up 25% of total net profit.

"The globalization of health care is changing service rapidly, and Apollo has been among the most aggressive in pursuing these opportunities," says Ofer Carmel, senior assistant to the director general of Maccabi Healthcare Services, a top Israeli health-care provider in Tel Aviv. Mr. Carmel says Maccabi is seeking to replicate some Apollo strategies.

Campus in the Hills

Apollo's focus on developing a global business is on display at its 17-year-old, 23-acre campus in the Jubilee Hills of Hyderabad, 500 miles north of Madras. About a dozen white-stucco office buildings stretch across the rolling land. Besides a hospital and nursing school, the buildings house Apollo's information-technology operations. Eucalyptus and bougainvillea line the roads. A Hindu temple has been erected for prayer, and the sound of worshipers reciting mantras can be heard from the hospital ward.

In a cramped conference room in one building on a recent day, Sangita Reddy, 41, one of Dr. Reddy's four daughters, gathered with staff around a pool-table-size model of the Hyderabad complex. In the group were architects and experts in the ancient Indian art of Vastu, a discipline focusing on mastering the universe's cosmic forces, such as water, fire and earth. The goal: identifying the most auspicious setting for a new building for foreign patients. A bad location could be harmful to their care, noted Cherukuri Sasidhar, one of the designers, who aims to blend Eastern and Western medicines and architecture.

In another room on the campus, 30 Apollo staffers pored over medical bills and insurance claims, some of the 400 data processors who move in and out of the information-technology wing each day. They have memorized hundreds of codes that correspond to different medical procedures. The unit's manager, Miriam Mamta Edwards, punched numbers for radiological procedures into her computer. On her cubicle hangs a sign: "I Came, I Saw, I Coded."

In another room, Apollo executive Divya Sehgal met with American health-care executives who had flown in to look at how Apollo is handling their company's remote billing operations. To accommodate more billing and claims operations, a floor has been cleared in the complex for 300 more workers.

Meanwhile, pathologist Shyamala Sesikeran was overseeing clinical trials for half a dozen Western pharmaceutical companies. Over the past year, her staff has studied the effects of antibiotics, cancer drugs and heart treatments on local residents.

"More people will come to India" for treatment, says Saif Salim Sulieman al-Ziyuti, who was at the complex with his cousin, Salim Ali Salim al-Ziyuti, for annual check-ups. They had traveled from their home in the United Arab Emirates, three hours away by air. "They take good care of you," says the white-robed Mr. Saif. The cousins say their medical care at home is first-rate, but a scheduling backlog means weeks of waiting.

For Dr. Reddy, one question hovers: How big can Apollo grow? Local politicians, among others, complain that the company's services are too expensive for the average Indian. "There needs to be a way for hospitals like Apollo to channel more of their profits to the poor," says Harsh Vardhan, a physician and former Indian health minister in New Delhi's capital region who now is a senior member of the ruling Bharatiya Janata Party.

Apollo executives say they are helping India's poor. The company sets aside beds for free care and has established a financial trust to aid the needy. The company also notes that new technologies, such as examining patients in remote areas via television monitor, allow Apollo to reach India's poor in ways doctors once couldn't. Apollo has set up nearly 60 "tele-medicine" centers over the past two years.

On a recent afternoon, Apollo doctors sitting around a conference table in Madras digitally connected to Dr. Reddy's hometown of Aragonda. The X-ray of a 10-day-old boy with a misplaced heart beamed into the room. "We can make a composite diagnosis in just one hour," says Vilva Nathan, a physician. "Before it could have taken days just to get the patient to the hospital."

US health authorities and the Central Intelligence Agency has warned that India, "Washington's closest ally in a dangerous part of the world", was sitting on a fast-ticking AIDS (Auto-Immune Deficiency Syndrome) bomb which could wreak havoc and can weaken the economy and military strength unless defused quickly.

Assessing AIDS in terms of the impact it could have on the world power equation, officials said India had to take strong measures before it is too late, a CBS current affairs programme said.

By some estimates, the most AIDS-infected region in the world is no longer Africa. "It is in Asia, and the country is India," the CIA was quoted as saying.

"If the epidemic is not contained soon, it could come back to haunt us -- weakening India's army and damaging India's economy, which is closely tied to ours. And it could even lead to a new epidemic of the virus back in the US," according to a CIA report quoted by CBS 60 minutes programme.

"The national security dimension of the virus is plain. It can diminish military preparedness and further weaken beleaguered states," CIA Director George Tenet said in the report.

This, said CBS, has not happened in India, "but it could, if the epidemic spreads any further. Experts say India is close to the tipping point." After that, the virus will spread too far to be contained. Right now, it is still India's prostitutes who have been hardest-hit, the programme said.

The programme showed Bombay's crowded red light areas where most of the women appeared reluctant discuss the disease. The few that did, however, said that condoms, the only thing between them and near-certain death, were bad for business.

The report quoted Dr Suniti Solomon, a social worker who detected AIDS among prostitutes more than a decade ago, as saying that, like in other parts of the world, the virus has spread well beyond the red light districts.

"I used to see a new patient every week during early 1990s," Solomon said. "Today, we see 10 to 11 new patients every day." That, said CBS, is why Solomon had set one of the first AIDS hospitals in India in Chennai.

She said roughly 20 per cent of her patients are truck drivers, who often frequent prostitutes. But 90 per cent of Solomon's female patients are not prostitutes but married women who have contacted HIV from their husbands.

Bill Gates, the world's richest man and founder of Microsoft, recently donated USD 200 million specifically to combat AIDS in India. Despite issuing the warning, the report said, the US government has offered less than 1 per cent of the entire money spent on AIDS to address the epidemic in India

A few days ago, my father was admitted to Apollo Hosp, Madras for a heart bypass. We admitted him there on the knowledge that it is one of the best hospitals in India. We signed a contract with them and agreed to pay a certain sum of money. The contract was kind of vague but basically said that, for the sum of money, all procedures and care will be covered for 11 days or so. Once he was admitted, the problems started. First, the surgeon postponed the op because he had 'personal committments'. Of course, we got charged for the days that my Dad was in the hospital and didn't have surgery. Then they said that we've to arrange for blood supplies ourselves (they would give us a list of donors but we would be taking a chance with them). This completely threw us for a loop. My sister sent an email around her office and got six donors. They all came to the hospital and then the staff told them to go home and come on the morning of the surgery. My bro-in-law had to fight with hospital staff to get them to take the blood and freeze it till the op. Then they insist on a family member to stay with the patient at all times. If the family member cannot stay then we will need to hire a nursing assistant to stay with patient. My sister says that there are no facilities for these nursing assistants. There are hundreds of them; sleeping on the floor, changing clothes and basically living/sleeping near patient. An ugly sight ! The surgery is scheduled for Mon and to top it all, they just informed my sister that we have to cough up another $1,000+ dollars for another procedure during the surgery and for having another doctor on call who is familiar with the procedure. Plus we have to pay for extra time to stay in the hospital. And it must be all paid before surgery. If this is the 'best' hospital in India - then God help us - we've along way to go. Expect, I'll hear of more problems before my Dad's stay is done.

Originally posted by Babui:A few days ago, my father was admitted to Apollo Hosp, Madras for a heart bypass. We admitted him there on the knowledge that it is one of the best hospitals in India. We signed a contract with them and agreed to pay a certain sum of money. The contract was kind of vague but basically said that, for the sum of money, all procedures and care will be covered for 11 days or so. Once he was admitted, the problems started. First, the surgeon postponed the op because he had 'personal committments'. Of course, we got charged for the days that my Dad was in the hospital and didn't have surgery. Then they said that we've to arrange for blood supplies ourselves (they would give us a list of donors but we would be taking a chance with them). This completely threw us for a loop. My sister sent an email around her office and got six donors. They all came to the hospital and then the staff told them to go home and come on the morning of the surgery. My bro-in-law had to fight with hospital staff to get them to take the blood and freeze it till the op. Then they insist on a family member to stay with the patient at all times. If the family member cannot stay then we will need to hire a nursing assistant to stay with patient. My sister says that there are no facilities for these nursing assistants. There are hundreds of them; sleeping on the floor, changing clothes and basically living/sleeping near patient. An ugly sight ! The surgery is scheduled for Mon and to top it all, they just informed my sister that we have to cough up another $1,000+ dollars for another procedure during the surgery and for having another doctor on call who is familiar with the procedure. Plus we have to pay for extra time to stay in the hospital. And it must be all paid before surgery. If this is the 'best' hospital in India - then God help us - we've along way to go. Expect, I'll hear of more problems before my Dad's stay is done.

Keep us updated Babui, first hand experience usually give more information than a thousand articles in newspapers, may god bless your father and family!

Raj - thanks for your good wishes. My father's op went well and he is recovering in ICU. I had a long talk with my sister and my aunt whose father underwent the same op in the same hosp a year ago. The consensus opinion is that the skill of the heart bypass team at Apollo Hosp, Madras is undeniable. However, the problems cited above leave a lot to be desired.

Apollo prides itself in attracting foreigners. I suspect (but am not sure) that foreigners (read 'Gora') are treated far better than us desis. I, simply, cannot imagine an American or Englishman being told before his op that he has to arrange for his own blood supplies

Ummm....I thought it was normal to arrange for blood for surgeries in India. I have given blood a couple of times both for relatives and for friends about to undergo surgeries in some very good pvt. hosptials in Mumbai.

Its is an unscientific but i guess socially acceptable means of acquiring untained blood. It also transfer the risk of infection from the hospital to patient's family.

Hinduja hosptial in Mumbai wrote off all medical costs for a gentleman known to us coz he contracted hepatitis from 'their' blood, if he kept quite. He did.

Blood and other biologics requires some stringent QC and technologies to be made safe and viable. Unfortunately the public health system in India cannot guarantee that at this moment, no matter how hard they try.

<a href="http://cities.expressindia.com/fullstory.php?newsid=84830">Blood banks in the red</a>

Originally posted by Babui:A few days ago, my father was admitted to Apollo Hosp, Madras for a heart bypass. We admitted him there on the knowledge that it is one of the best hospitals in India. We signed a contract with them and agreed to pay a certain sum of money. The contract was kind of vague but basically said that, for the sum of money, all procedures and care will be covered for 11 days or so. Once he was admitted, the problems started. First, the surgeon postponed the op because he had 'personal committments'. Of course, we got charged for the days that my Dad was in the hospital and didn't have surgery. Then they said that we've to arrange for blood supplies ourselves (they would give us a list of donors but we would be taking a chance with them). This completely threw us for a loop. My sister sent an email around her office and got six donors. They all came to the hospital and then the staff told them to go home and come on the morning of the surgery. My bro-in-law had to fight with hospital staff to get them to take the blood and freeze it till the op. Then they insist on a family member to stay with the patient at all times. If the family member cannot stay then we will need to hire a nursing assistant to stay with patient. My sister says that there are no facilities for these nursing assistants. There are hundreds of them; sleeping on the floor, changing clothes and basically living/sleeping near patient. An ugly sight ! The surgery is scheduled for Mon and to top it all, they just informed my sister that we have to cough up another $1,000+ dollars for another procedure during the surgery and for having another doctor on call who is familiar with the procedure. Plus we have to pay for extra time to stay in the hospital. And it must be all paid before surgery. If this is the 'best' hospital in India - then God help us - we've along way to go. Expect, I'll hear of more problems before my Dad's stay is done.

Babui,

Appollo is all hype. Its a very unscrupulous place and very loose on ethics. I can tell u a bunch of horror stories, including one close relative and a friend. Be very careful and circumspect on any expensive surgical procedures and make sure you get an unbiased second opinion.

Suggestion: Change "industry" to "services" in the thread title. IMVHO the care available to aam janata is more important than that available to those with the means.

NHS: If it helps, I read articles in UK on how NHS was not sufficient (read sucks) and patients were flying out to Poland to receive treatment. This was around first 2 weeks of March if you wanna dig up the papers.

Manne: Any single payor/universal healthcare system which has any semblence of cost-containment will push back elective surgeries. But at least every citizen is has guaranteed coverage for acute and chronic conditions. Whilst in a mostly private delivery with public monies system like the US has healthcare on DEMAND provided you are eligible and provided its covered. This means 48 million get screwed and the elderly now have choose between 6 trillion rx cards just to find out they dont save any money over canadian pharmacies. You cant have the cake and eat it too in any system.

Unless you want to dole out 40% in taxes (in a country with the size and population less then MP) I cant think of any way in making a system equitable, accessable and with great patient satisfaction. Thats the way this game is played.

Originally posted by Manne: NHS: If it helps, I read articles in UK on how NHS was not sufficient (read sucks) and patients were flying out to Poland to receive treatment. This was around first 2 weeks of March if you wanna dig up the papers.

There are going to be critics for every system. Yeah, there are some improvements required. Sometimes some counties or some facilities get a little lax and everyone complains about it(Implementation might be a bit weak). All that news makes it into papers and tabloids happily print all this. But by and large, its easy to get a appointment, see your docteur and see him often if he agrees. Its longer to get an appointment in this country with my doctor than it is there. But thats a different issue.